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HIQA’s infection prevention and control inspections in hospitals during June and July 2018

Date of publication:Friday, 26 October, 2018

Four inspection reports on infection prevention and control practices in public acute hospitals have today been published by the Health Information and Quality Authority (HIQA). HIQA monitors infection prevention and control in hospitals against the National Standards for the prevention and control of healthcare-associated infections in acute healthcare services.

These inspections were conducted by HIQA following the declaration of a National Public Health Emergency Plan to address Carbapenemase-Producing Enterobacteriales (CPE) – a very resistant type of bacteria that can cause serious infections – by the Minister for Health on 25 October 2017. HIQA’s inspections focused on how hospitals are implementing the National Standards, with a particular examination of how patients are being protected against the CPE threat.

Inspections were carried out between June and July 2018 at:

Our Lady’s Children’s Hospital, Crumlin

St. Columcille’s Hospital, Loughlinstown

Croom Orthopaedic Hospital, Co Limerick

Mallow General Hospital, Co Cork.

The Health Service Executive (HSE) revised the requirements for screening of patients for CPE in the acute hospital sector in February 2018 to be implemented in all hospitals from 1 March 2018. Screening allows hospitals to better reduce the risk of colonised patients going on to develop CPE infection during the course of their medical treatment, and also enables the hospital to better prevent potential spread of CPE to other patients and staff.

HIQA notes that only one of the four hospitals inspected between June and July 2018 were in full compliance with the HSE guideline on screening patients for CPE. Given that the threat associated with CPE has been declared a national public health emergency, HIQA escalated concerns to hospital management in three hospitals and the HSE to seek assurances around how each hospital might ensure compliance with the HSE’s own guidelines. Full details of how each hospital intended to address this serious deficit are outlined in each report.

A summary of key findings from each inspection are further outlined below.

Our Lady’s Children’s Hospital, Crumlin

An unannounced inspection was carried out at Our Lady’s Children’s Hospital Crumlin on 15 June 2018. Overall, HIQA found that Our Lady’s Children’s Hospital, Crumlin had made significant progress in implementing the National Standards for the prevention and control of healthcare-associated infections in acute healthcare services. Effective leadership, governance and management arrangements were evident around the prevention and control of healthcare-associated infection at the hospital.

The hospital was not adhering to the national HSE patient screening guidelines for CPE. In light of the current national public health emergency, HIQA considered this to be a potential high risk that required escalation to hospital management. In response, the Chief Executive Officer (CEO) and the Consultant Microbiologist explained that due to differing multidrug-resistant organism’s epidemiology in paediatric settings when compared to adults, the hospital considered it appropriate to modify the national CPE screening guidelines. HIQA was informed that the adapted approach was risk assessed based on clinical opinion, previous screening and national surveillance data. In light of this response HIQA was satisfied that the hospital was actively managing this risk and accepted these assurances. To date, the hospital has not had a case of CPE cross transmission within the hospital.

HIQA also acknowledges the hospital’s positive progress and compliance levels in relation to:

clear oversight of performance across all clinical areas in relation to infection prevention and control was facilitated by ongoing surveillance, monitoring and audit programmes led by the infection prevention and control team

a high level of compliance with the multidrug-resistant organisms screening guidelines

an extensive environmental screening programme

hand hygiene standards

environmental hygiene standards, despite infrastructural challenges.

HIQA recommended that the hospital puts measures in place to address further opportunities for improvement, with particular emphasis on:

improvements in equipment hygiene and oversight of this

CPE screening guidelines must be uniform across all inpatient wards

targeted educational and audit is performed within the consultant group in order to drive improvement in hand hygiene compliance.

St. Columcille’s Hospital, Loughlinstown, Co Dublin

An unannounced inspection was carried out at St. Columcille’s Hospital on 21 June 2018. Inspection findings showed that the hospital had successfully addressed the issues identified in HIQA’s previous unannounced inspection in 2016. Notwithstanding that dated infrastructure posed many challenges for staff and patients at the hospital, it was evident that the hospital’s interior was maintained to an acceptable standard to facilitate effective cleaning and compliance with infection prevention and control best practice in the clinical area inspected.

In light of the focus of this inspection and the public health emergency in relation to CPE, HIQA found that the hospital had not ensured full implementation of the latest CPE national screening guidelines. The hospital had identified this as a high risk and had entered it on the hospital’s risk register and escalated it accordingly. HIQA wrote to hospital management to seek assurance on CPE screening in the hospital. In response, the General Manager provided assurances regarding arrangements put in place to actively manage this risk in the interim of full CPE screening compliance. It is imperative that the hospital is fully supported both at hospital group and national level in their endeavours to fully mitigate this risk.

The hospital had many elements of an infection prevention and control programme in place, including:

clear lines of accountability and responsibility in relation to governance and management arrangements

systems in place to identify and manage risk pertaining to the prevention and control of healthcare-associated infections

ongoing monitoring of infection prevention and control process and outcome measures

a structured antimicrobial stewardship programme

compliance with the HSE national performance indicator for hand hygiene.

The clinical area inspected was maintained to a high standard and overall the patient environment and equipment was clean. The hospital should continue to build upon its infection prevention and control audit programme, including carrying out regular patient care equipment hygiene audits across the hospital. Similarly, the hospital should continue to build on the progress to date to fully embed infection prevention care bundles audits into routine practice.

Croom Orthopaedic Hospital, Croom, Co Limerick

An unannounced inspection was carried out at Croom Orthopaedic Hospital on 10 July 2018. During this inspection inspectors identified that, in contrast to the other three hospitals inspected during June and July 2018, this hospital had ensured that the national HSE patient screening guidelines for CPE were fully implemented.

The hospital had formalised governance and management arrangements in place in relation to the prevention and control of healthcare-associated infection at both hospital and hospital group level. The infection prevention and control team (IPCT) based at University Hospital Limerick (UHL) provided and monitored the implementation of the infection prevention and control programme at the hospital. HIQA determined in previous reports that these resources were insufficient, as UHL provided cover to five of the six hospitals in the group. During this inspection, staff told inspectors that since January 2017 additional resources had been provided to the IPCT.

HIQA identified many good practices in relation to the infection prevention and control programme during this inspection. The hospital was in compliance with the national hand hygiene compliance target set by the HSE. The majority of staff were up-to-date with hand hygiene and infection prevention and control training in the clinical area inspected. Care bundle implementation to prevent invasive device-related infection had been well embedded and patient equipment was generally clean in the area inspected.

However, it was of concern that significant findings made during the 2014 and 2016 HIQA inspections, in particular in relation to the hospital fabric and infrastructural deficiencies, which had also been identified and escalated as risks by the hospital, had not been prioritised and addressed at corporate HSE level.

The Executive Management Team of the UL Hospitals Group need to address the following:

infrastructural deficiencies and inadequate provision of single rooms

oversight of environmental hygiene

contrary to recommendations by the hospital’s IPCT and HIQA findings in previous inspections, large ceiling fans remained in operation in multi-occupancy patient rooms in a clinical area that specialised in orthopaedic surgery. Assurance was not provided at the time of inspection that these fans were consistently cleaned in line with national guidelines

inadequate preventative maintenance programmes.

Mallow General Hospital, Cork

An unannounced inspection was carried out at Mallow General Hospital on 18 July 2018. HIQA identified that screening for CPE was not in line with the latest national guidance. In light of the current national public health emergency and a recent CPE outbreak experienced in another hospital within the region, HIQA considered this to be a high risk that required escalation to hospital management following this inspection. In response to HIQA’s letter, the General Manager outlined key actions which would be explored to manage this risk.

HIQA acknowledges the hospital’s progress in relation to:

environmental hygiene standards, despite infrastructural challenges

hand hygiene standards

the provision of staff education and the availability of policies for the prevention and control of healthcare-associated infection

minor refurbishment works completed with surfaces and finishes that readily facilitated effective cleaning in some ancillary and patient care facilities.

Standard 5.8 of the National Standards for Safer Better Healthcare identifies prompt action on recommendations made by a regulatory body as a key feature of effective governance, leadership and management. HIQA identified similar issues during the 2016 unannounced inspection and these issues had yet to be addressed.

In order to comply with national standards, hospital management need to put measures in place to address the following:

infrastructural deficits as identified in a number of HIQA inspections at the hospital

screening and microbiological testing arrangements with Cork University Hospital to ensure compliance with national screening guidelines in relation to multi-drug resistant organisms

review of the mechanisms in place to assure management that water supply and systems are developed and managed to minimise the risk of service users, staff and visitors acquiring a healthcare-associated infection.

Notes to Editors

A National Public Health Emergency Plan was activated on 25 October 2017 by the Minister for Health in response to the increase and spread of Carbapenemase-Producing Enterobacteriales (CPE) in Ireland. As a result a National Public Health Emergency Team was convened. Further details as to the work of this team may be viewed here.

Carbapenemase-Producing Enterobacteriales (CPE) is the newest in a long line of 'superbugs' (bacteria that are hard to kill with antibiotics). Of all the superbugs, CPE is among the most difficult to kill with antibiotics. It is carried in the bowel and can cause blood stream infection in people who are vulnerable, such as the elderly and those with low immunity. More than half of all patients who develop blood stream infections with CPE die as a result of their infection. Further details may be found on the HSE website.

People may be either colonised or infected with CPE. People who are colonised with CPE have the bacteria present in a part of their body (usually in the bowel) where it lives without causing an infection. Infection can occur when the CPE bacteria is either directly introduced to, or enters other parts of the body which are normally sterile such as the bloodstream. Screening for CPE in patients who have risk factors that make them more likely to be colonised is a critically important control measure because knowing who is colonised can allow measures to be put in place so that they are better protected from risk of infection, and so that the bacteria does not spread further to other patients or staff.

The HSE has developed detailed national screening guidelines that are available to view here.